Death in low-risk cardiac surgery: the failure to achieve a satisfactory cardiac outcome (FIASCO) study

Abstract

Death in low-risk patients is not studied as frequently as it is in other cardiac patients. We, therefore, sought to determine why some low-risk patients die after cardiac surgery. All low-risk patients (EuroSCORE<or=2) who died after cardiac surgery in one institution between 1996 and 2005 were included and meticulously studied by internal and independent external review of preoperative, operative and postoperative information from the case-notes and post-mortem findings. Deaths were classified into non-cardiac and cardiac and further subclassified into unavoidable deaths or due to failure in achieving a satisfactory cardiac outcome (FIASCO). Between 1996 and 2005, there were 16 deaths in 4294 low-risk patients (mortality 0.37%). Internal and external review agreed that nine deaths were non-preventable (CVA, bronchopneumonia, etc.) and that avoidable FIASCO accounted for seven deaths. Of the deaths considered to be preventable, all had probable errors of technique and three also had additional system errors. No cardiac operation is without risk. Mortality, though fortunately rare, can still occur, even in low-risk patients. Despite an extremely low mortality in the low-risk group FIASCO still accounts for nearly one-half of deaths. This suggests that mortality may be reduced even further as part of a quality improvement programme.

Coronary ostial compromise in aortic valve replacement: An avoidable complication

“…In the FIASCO studies, we and others have shown that it is possible to identify factors associated with death in low-risk cardiac surgery patients and that modifying such factors can result in a reduction of avoidable mortality. [6][7][8] The aim of the current study was to look into the mechanism of coronary ostial compromise during AVR in the hope that understanding the prevalence and mechanisms of this complication may help future prevention of such unwanted events. Coronary ostial compromise in AVR is a rare but real problem.…”

Mortality in low- and very low-risk patients undergoing cardiac surgery: Evaluation according to the EuroSCORE II as a new standard

“…Perioperative death in low-risk patients is uncommon and had not been thoroughly studied until recently [3][4][5][6][7]. Previous studies defined low--risk with a logistic EuroSCORE ≤ 2 or an additive EuroSCORE ≤ 3, and investigated whether death could be considered preventable due to a technical or system error.…”

“…Although the observed in-hospital mortality in very low-risk patients was 0.93%, the expected risk based on the EuroSCORE II was even lower (0.70), and this difference could reach statistical significance in a larger sample. Table 3 summarizes the findings of different studies analyzing death in low-risk patients and virtually 3 of them (from United Kingdom [3,4] and Sweden [5]) showed mortality rates well below 1%. The remaining 2 studies from Turkey reported similar results to ours, though they only included coronary artery bypass grafting that has a well-known lower risk of operative mortality than other types of open heart surgery [6,7].…”

“…We defined non-preventable death when the cause was an unavoidable and unpredictable event such as pulmonary embolism, stroke, mediastinitis, septicemia or sudden death after discharge. Definitions of technical and system errors were adopted from previous FIASCO studies [3,4].…”

“…To date, only a few reports have analyzed the outcomes in low-risk patients, and in every case risk has been calculated based on a logistic Euro-SCORE ≤ 2 [3][4][5][6][7]. Since this original EuroSCORE overestimates operative risk [8], we developed this study to prospectively evaluate the immediate results of cardiac surgery in patients with an expected mortality risk ≤ 2% according to the EuroSCORE II as a new gold-standard.…”